Practice Tips

Patient Handoff

There are many terms used for the patient handoff process, e.g., handover, sign-out, shift report, etc. According to The Joint Commission Sentinel Event Alert Issue 58, a patient handoff is “a transfer of and acceptance of patient care and responsibility achieved through effective communication. It is a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another to ensure the continuity and safety of the patient’s care.”

Importance of Patient Handoffs

Patient handoffs provide safe transitions and continuity of care as the patient moves through various healthcare settings and eventually is discharged from care. Handoff communication is used to review the most crucial information related to the patient’s transfer. Unstructured handoffs have the potential for patient harm and increase medical errors. When patient handoff communication fails to provide the patient-specific information necessary to ensure the patient continues to receive appropriate care, the potential for patient harm can range from minor to severe. Inadequate patient handoffs increase patient safety risks and have been directly identified with delays in patient care, inappropriate treatment, medication errors, wrong-site surgery, errors of omission, avoidable readmissions, increased length of hospital stay, and other avoidable patient harm.

Current State of Risk

Communication failures are consistently identified as one of the leading causes of significant patient events (including Sentinel Events). The 2023 Joint Commission Sentinel Event Data Review, released in 2024, outlines the top sentinel events and their contributing factors. Within those factors, inadequate staff-to-staff communication during handoffs or transitions was a major contributor. As with previous years, failures in communication, teamwork, and consistently following policies were leading causes for reported sentinel events.

Eighty percent of medical errors involve miscommunication between providers during patient handoffs at transitions of care. Patient handoffs are complex and require excellent communication between the sender and the receiver of the patient information. Communication failures increase the risk of patient and family dissatisfaction which is a leading contributor to professional licensure complaints and malpractice claims.

Typical Patient Handoffs That Occur in the Healthcare Continuum Where Risk Can Occur

Change in Level of Care:

• Long-term care, skilled care, home health, physician practice to the ED
• Outpatient area (ED, clinic, ambulatory unit) to an inpatient setting
• Acute care to ICU or surgical services and vice versa

Short-term Transfer of Care:

• Movement from primary care location (inpatient, ED, community-based organization) to diagnostic service and back
• Change in caregiver (shift change, call coverage)

Discharge:

• From inpatient to long-term care, skilled care, or home health
• Inpatient to home with PCP and/or referral follow-up

Challenges in Patient Handoffs

Patient handoffs are a significant challenge in health care due to their high frequency, lack of structure or tools for them, ineffective communication skills, distractions, interruptions, timing, lack of time, staff, and even documentation of those handoffs.

Common reasons identified for handoff communication failures include:

• Handoff not appropriately timed between sender and receiver (room is not ready, or change of shift)
• Insufficient resources allotted for handoff (inadequate time/staffing/equipment)
• Location is noisy, prone to interruption
• Patient and/or family not included in the process
• Sender does not have adequate information about the patient; therefore, provides inadequate handoff
• Sender unable to contact receiver in a timely manner
• Sender has to repeat information that has already been shared
• Receiver is unaware of the transfer or has competing priorities

How Patient Handoff Communication Can Be Improved

• Make high-quality patient handoffs a priority for helping to sustain a culture of patient safety
• Develop/update handoff policies and procedures
• Standardize critical content to be communicated
• Prepare report ahead of time, gather pertinent information from available resources
• Tailor the process to the users, the environment where the handoff is occurring, and the type of patient, i.e., ED
• Consider using a standardized tool
• Reinforce handoff by documentation of the information provided
• Include all team members as appropriate and involve the patient and family

Communication Skills

High-quality patient handoffs require excellent communication skills between the person/team sending the patient (sender) and the person/team receiving the patient (receiver) to ensure the receiver understands the patient care information provided by the sender. 

Excellent communication skills require both the sender and receiver to:

• Seek information (ask pertinent questions: “Is there anything else I should know”)
• Give information (clear, concise, and complete)
• Verify information (clarify, repeat back, double-check calculations/equipment settings)
• Validate each other (communicate with warmth and respect, thank the other, keep remarks objective)
• Use clear language. Avoid unclear or potentially confusing terms (“she’s a little unstable,” “he’s doing fine,” or “she’s lethargic”). Avoid abbreviations or jargon that could be misinterpreted. Speak using a moderate pace

Educate the key players:

• Provide training for new staff and annual education for existing staff
• Emphasize the importance of quality patient handoff information
• Communicate with staff that a patient handoff is always required
• Teach effective handoff skills, including assertiveness when there are questions and listening skills
• Discuss how stress, fatigue, and information overload can affect understanding
• Address cultural variations in communication
• Provide consistent expectations for compliance with handoffs
• Document the handoff in the medical record. Receiver- whom the receiver received the handoff from and Sender- whom they communicated the handoff to

Plan the handoff:

• Coordinate resources such as patient information, transport equipment, and personnel
• Allow adequate time for handoff
• Perform at the bedside allowing for direct patient visualization and communication between caregivers. Minimize distractions and interruptions. If not at the bedside, choose a quiet location and maintain patient privacy
• Encourage the patient and family to participate. Address any family needs or concerns

Use a standardized form or tool:

Standardize critical content to be communicated. Tailor the handoff protocol to its users, the environment in which the handoff occurs, such as the emergency department, and the type of patient.

Examples include:

• Checklists such as a pre-operative, pre-MRI, “ticket to ride” and discharge

Tools:

ISBARR

• Introduction - introduce yourself, including your department and role
• Situation - specify the situation. What has triggered this conversation, and what is the patient’s current condition
• Background - diagnosis, pertinent medical history, care to date
• Assessment - assess current needs, any outstanding studies or information
• Recommendation - explain what is being requested (“I would like you to see the patient now,” or “I would like to schedule the ambulance, when will you be ready to receive the patient”)
• Repeat - ask the receiver to summarize the important details and ask if there are any questions

I-PASS

• Illness Severity
• Patient Summary
• Action List
• Situation Awareness and Contingency Planning
• Synthesis by Receiver (Pediatrics 2012)

ISHAPED

• Introduce - allergies, code status, contact information, advance directives, provider teams, ancillary consults.
• Story - hospital problem, treatment plan, admission screening information, learning assessment
• History - pertinent emergency department summary, history and physical, medical and surgical history, and any blood administration history for the past 72 hours (links in EHR if electronic tool)
• Assessment - vital signs, activities of daily living, diet orders, pain management, assessments, current medications, intake and output summary, lab results, radiology results from the past 24 hours
• Plan - care plan goals, orders to be acknowledged and completed, current infusions, as-needed medications, nursing orders, patient-initiated and patient-advocate goal documentation
• Error Prevention - high-alert warnings, patient-specific medication information
• Dialogue - shift report given, how patient and family were involved

Monitoring the Handoff Process

• Monitor the success of the handoff process and use data to identify opportunities for improvement
• Evaluate and measure handoff adverse events and use data to identify opportunities for improvement

References

ACOG. Committee on Patient Safety and Quality Improvement. Committee Opinion Number 517. Communication Strategies for Patient Handoffs. February 2012. Reaffirmed 2018

Agency for Healthcare Research and Quality. (2008). Pocket Guide: TeamSTEPPS. Strategies & Tools to Enhance Performance and Patient Safety. AHRQ Publication No. 06-0020-2, Rockville, MD. Revised 2013

Melissa Desmedt, Dorien Ulenaers, Joep Grosemans, Johan Hellings, Jochen Bergs, Clinical handover and handoff in healthcare: a systematic review of systematic reviews, International Journal for Quality in Health Care, Volume 33, Issue 1, 2021

Freel, Jo and Fleharty, Brandon. “Standardizing Handoff Communication” American Nurse Journal Volume 16, Number 3. Updated 2021

Starmer AJ, Spector ND, O'Toole JK, et al. and the I-PASS SHM Mentored Implementation Study Group. Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. J Hosp Med. 2023 Jan;18(1):5-14. doi: 10.1002/jhm.12979. Epub 2022 Nov 3. PMID: 36326255; PMCID: PMC10964397.

The Joint Commission, Sentinel Event Alert “Inadequate hand-off communication”, Issue 58, September 12, 2017.

The Joint Commission “8 Tips for High-quality Hand-offs” 2017

Perfecting the Patient Hand-off: 3 Ways to Improve Your Hand-off Process October 9, 2015 Categories: blog

The Joint Commission Center for Transforming Healthcare, “Improving transitions of care: Hand-off communications”, 2014.

The Joint Commission Sentinel Event Data 2023 Annual Review

Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.

Toolkits

AHRQ TeamSTEPPS: National Implementation

AORN Perioperative Patient ‘Hand-off’ Tool Kit

The Joint Commission, Targeted Solutions Tool for Handoff Communications, 2017